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CQC report explained · a nursing home

What the CQC found at Edgeview Nursing Home

Goodpublished 21 April 2023, 3 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People received medicines as prescribed and were supported by enough staff. Inspectors found some unsafe environmental items and missing water temperature records, but the management team took immediate action.
Effective?
Good
This key question was not assessed during this focused inspection. Its previous rating was carried forward, but that rating is not stated in this report.
Caring?
Good
This key question was not assessed during this focused inspection. Its previous rating was carried forward, but that rating is not stated in this report.
Responsive?
Good
This key question was not assessed during this focused inspection. Its previous rating was carried forward, but that rating is not stated in this report.
Well-led?
Requires improvement
Governance checks did not always identify invalid restrictions, environmental hazards or communication gaps. Staff supervision was sporadic and some training was incomplete.
The latest report, explained

What inspectors found, April 2023

Edgeview Nursing Home was rated Good overall, but inspectors found that leadership and checks needed improvement.

This was an unannounced focused inspection on 25 January and 1 February 2023. Inspectors spoke with people, staff and health professionals, and checked care files, medicines records, recruitment files and management records.

The home was rated Good for Safe. People received medicines as prescribed, staffing was sufficient, risks to individuals were understood and safeguarding procedures were known. Inspectors found no evidence that the concern which led to the inspection had harmed anyone.

The home was rated Requires Improvement for Well-led. Checks did not always identify environmental hazards, outdated restrictions, incomplete handover information, irregular staff supervision and training still to be completed. The manager took some immediate action during the inspection.

The overall rating stayed Good because this inspection only assessed Safe and Well-led. The other areas were not inspected and their previous ratings were carried forward from the last inspection.

What inspectors praised
  • Medicines

    Nursing staff were trained to give medicines, and inspectors found that people received them as prescribed. Instructions for medicines given when needed were detailed and personal to each person.

    “The nursing staff ensured people received their medicine as prescribed.” from the report
  • Staffing and recruitment

    Inspectors found enough staff to meet people's needs, including most one-to-one support hours. Recruitment checks were robust.

    “People were supported by sufficient numbers of staff.” from the report
  • Understanding individual risks

    Staff understood people's needs and the steps needed to reduce individual risks. Health professionals confirmed that the home worked with them on support plans.

    “People's individual risks were assessed, and staff had a good understanding of the risk reduction measures required to help keep people safe.” from the report
  • People's views

    People, relatives and professionals were asked for feedback. People spoken to by inspectors were complimentary about the home and its management.

    “People, relatives and professionals were encouraged to give feedback on care.” from the report
What inspectors were concerned about
  • Environmental safety checks

    serious

    Inspectors found an unlocked sluice room containing hazards, thickener that was not safely stored and no records showing that water temperatures had been checked. No one was found to have been harmed.

    “For example, the sluice room contained hazards and was unlocked, drinks thickener had not been returned to safe storage, and water temperature checks were not being documented, meaning we could not be assured they were happening.” from the report
  • Restrictions and legal reviews

    serious

    Some reviews of restrictions and authorisations were needed. One fluid restriction was no longer medically necessary, and another record contained the wrong medicine dosage.

    “However, we found reviews of people subject to DoLs were required.” from the report
  • Communication and management checks

    needs fixing

    The handover system was not always fully used, so important changes might not reach all staff. Staff supervision was sporadic, although its frequency was increasing.

    “There was a handover system in place, however it was not always fully utilised.” from the report
  • Training

    needs fixing

    Some staff needed to update safeguarding training, and some had not completed learning disability training. Staff spoken to still understood the safeguarding process.

    “The training records indicated a number of staff needed to update their training, however all the staff we spoke with were able to explain the process they would follow if they became concerned.” from the report
Questions to ask them, based on this report
  1. 01How have you checked that all restrictions and Deprivation of Liberty Safeguards authorisations are still necessary and contain correct information?
  2. 02What has changed to keep the sluice room locked, store drinks thickener safely and record water temperature checks?
  3. 03How do you make sure important changes are recorded and passed on during staff handovers?
  4. 04What is the current plan for completing safeguarding and learning disability training, and for providing regular staff supervision?
  5. 05What are the current ratings and most recent findings for Caring, Effective and Responsive, which were not assessed in this inspection?

This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection, and the supported living premises and regulated activity were not reviewed. This explanation was written from the published report of 21 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

An earlier report, explained

What inspectors found, March 2020

Edgeview Nursing Home is Rated Good; inspectors found safe, kind and well-managed care, with some concerns about the building and record keeping.

This was an unannounced, planned inspection on 4 February 2020. One inspector and a nurse specialist spoke with seven people, nine staff and reviewed care, medicine, staffing and management records.

The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were treated with respect, supported to make choices, given suitable care and helped to access health services and activities.

The home had improved from Requires Improvement at the previous inspection, published in February 2019. However, the building and location did not fully match best practice for people with learning disabilities or mental health needs. Some care reviews were not dated, and certain light-switch pull cords were not easy to clean.

What inspectors praised
  • Kind and respectful care

    People appeared comfortable with staff. Staff knew people's interests, preferences and communication needs, and supported privacy and independence.

    “People were relaxed in the presence of staff and there was evidence of warm and friendly relationships.” from the report
  • Activities and relationships

    People were supported to take part in activities, go out and maintain friendships. The home had dedicated activities staff and an activities room.

    “People were supported by dedicated activities staff who were enthusiastic about their work in engaging people in activities and pastimes they enjoyed.” from the report
  • Good oversight

    Managers were visible and approachable. The provider used audits, surveys and incident reviews to monitor care and make improvements.

    “The provider had a range of effective quality monitoring arrangements in place.” from the report
What inspectors were concerned about
  • Building and location

    needs fixing

    The home was not designed in line with best practice guidance for people with learning disabilities or mental health needs. Its hilltop location and distance from local facilities could make independence harder, although transport was available.

    “The location and structure of the current building did not reflect the values of Registering the Right Support” from the report
  • Some records were not dated

    minor

    Monthly care reviews were not always dated. Inspectors said adding dates would help staff follow the records over time.

    “These were not always dated however which would help with the continuity of the records.” from the report
  • Light-switch pull cords

    needs fixing

    Some pull cords were not easy to clean and could provide places for bacteria. The provider said it would look at replacing them.

    “There were some pull cords from light switches that may have presented a containment area for bacteria” from the report
Questions to ask them, based on this report
  1. 01What changes have you made to the light-switch pull cords since the inspection?
  2. 02How are you ensuring that every monthly care review is dated and easy for staff and families to follow?
  3. 03What plans are being considered to improve the building so people have more choice, control and independence?
  4. 04How does the available transport help residents reach local facilities and take part in community activities?
  5. 05How will you continue the improvements that led to the rating rising from Requires Improvement to Good?

This was an unannounced planned inspection covering all five CQC questions, including the care provided and the premises. This explanation was written from the published report of 26 March 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Edgeview Nursing Home

6 rated inspections over 8 years: the service has held its Good rating throughout.

  1. April 2023Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Edgeview Nursing Home →

  2. March 2020Goodup from Requires improvement
    Safe: GoodWell-led: Good

    Read what inspectors found at Edgeview Nursing Home →

  3. February 2019Requires improvementup from Inadequate
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  4. June 2018Inadequatedown from Requires improvement
    Safe: InadequateEffective: Requires improvementCaring: InadequateResponsive: InadequateWell-led: Inadequate

    Read this report on cqc.org.uk

  5. March 2017Requires improvementdown from Good
    Safe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. November 2014Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  7. October 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. December 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. June 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. January 2011

    Registered with the Care Quality Commission on 10 January 2011.

Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.

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